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Tuesday, 2 December 2014

Médecins Sans Frontières, one of the key charities on the frontline of tackling the ongoing Ebola outbreak in West Africa, has in recent weeks been calling for a global military intervention to contain the disease. Joanne Liu, the International President of MSF, told the UN in early September that the further spread of the disease "will not be prevented without a massive deployment". Liu repeated this call in an interview published in the British Medical Journal in which she said that “The military are the only body that can be deployed in the numbers needed now and that can organise things fast.” She went on to give another reason for a military-based response: “I think with the massive investment and knowing how much they are afraid of bioterrorism, they have some knowledge about highly contagious diseases.”

After being heavily criticised for many months of inaction on Ebola, Western governments are now beginning to deploy troops across the countries most affected by the outbreak. At the time of writing the US has sent approximately 4,000 troops to Liberia, where they have been involved in building treatment units and training medical workers. Further deployments are promised. The UK is sending a ship (RFA Argus), along with 750 soldiers and medics to Sierra Leone. Meanwhile, United Nations Secretary-General Ban Ki-Moon has bemoaned the fact that a $1 billion trust fund launched by the UN has only received $100,000 in donations. Some of the major Western powers, it seems, see sending troops as preferable to channelling financial donations via the UN.

In some ways it is easy to see why. The lack of human resources on the ground in West Africa is a major obstacle facing the containment effort. This is not a new problem: Sierra Leone and Liberia jointly rank 194th in the world (out of 200) when it comes to the number of physicians per 1,000 people, with Guinea only slightly ahead at 173rd. It is no wonder that Ebola has stretched these meagre resources far beyond their limits. As Joanne Liu argues, Western militaries appear to have the capacity to deploy teams quickly and in large numbers – not only military medics, but also troops who can contribute to building the necessary physical infrastructure.

Deploying the military to pursue undoubtedly worthy humanitarian ends, however, needs to be handled with great care. Whilst the logistical capacity and human resources that militaries have may seem to make them the ideal people to send to West Africa (a choice which seems even more natural given that Western governments, including those in the US and the UK have interpreted Ebola as a threat to their own national security and have ‘declared war’ on the disease) there are significant political (and, potentially, health) risks in doing so.

First, it is far from clear that these militaries actually do have the necessary expertise and experience. Nancy Lindborg from USAID told the Washington Post that there was a lack of military medical personnel with the relevant expertise, hampering the US’s ability to effectively provide assistance. The preparedness for bioterrorism that Joanne Liu identified makes extensive use of civilian public health personnel as well as the military, while the military medics deployed in theatre are trained and equipped for short term immediate care (often battle related) rather than the demands of a highly pathogenic virus. Even the RFA Argus, a ship specifically designed to receive casualties, has such limited facilities for highly contagious patients that it will not be receiving any local patients on board. What militaries do have extensive experience of over the past two decades of humanitarian deployments is in infrastructure projects – but this is perhaps best seen as a long term preventive strategy rather than a short term response to an urgent need.

Second, there are real causes for concern over how the arrival of international troops sent to ‘battle Ebola’ will be received within the region. Trust in the authorities is a vital part of any disease containment effort, and all-too-often it has been lacking during this Ebola outbreak where people in all three of the most-affected countries have feared not only the disease itself, but also the attempts of the authorities to implement containment measures. A team of eight health workers was killed in Guinea, and there have also been attacks on teams of aid workers burying dead bodies. Liberia has seen violent clashes between the public and the police and military as they attempted to enforce emergency quarantine arrangements. In Sierra Leone, police used tear gas against protesters complaining about the inadequacy of the response to the outbreak and a treatment center was attacked. These are just a small number of examples of a widespread and pervasive lack of trust which continues to hamper containment efforts. It is quite possible that the presence of foreign troops will exacerbate rather than ameliorate this problem.

Rumours in some areas that the West is responsible for creating Ebola in the first place increase this danger. Significant attention was garnered by a piece in the Liberian Daily Observer written by Dr. Cyril Broderick, a Professor of Plant Pathology at the University of Liberia, who argued that Ebola (as well as AIDS) had been manufactured as a bioweapon and that “Reports narrate stories of the US Department of Defense (DoD) funding Ebola trials on humans, trials which started just weeks before the Ebola outbreak in Guinea and Sierra Leone.” Whilst we should be careful not to overstate the extent to which such claims are believed by people in the region, there is a constituency for them – one which is unlikely to be dissuaded from its belief by the arrival of Western uniformed troops.

Third, these deployments are in danger of furthering the zeitgeist of the militarisation of aid. In Iraq and Afghanistan in particular, but in emergencies elsewhere on the planet, the US military has been at the forefront of both the ‘war on terror’ and the delivery of humanitarian aid, often in the same country and even at the same time. Indeed the US has been explicit about the benefits of aid in the war on terror, as a form of ‘soft power’. The result is a blurring of the distinction of the military being used instrumentally for political gains, and the delivery of aid for humanitarian purposes. The result is not simply a scepticism over Western intentions when they deploy their militaries for humanitarian purposes, but the targeting of aid workers because the distinction between aid and politics has been undermined.

Fourth, and above all, if we see the deployment of the military as our response to ‘combat emergencies’, this misses the point that what we need are upstream prevention and early control measures not downstream band aids. Ebola is only the latest in a series of disease outbreaks which have required emergency responses, but which might have been prevented from becoming epidemics if better public health systems (including improved disease surveillance capacities) were in place. The system for identifying and reporting disease outbreaks has improved dramatically in some parts of the world from the time when local officials in Guandong could hide the emergence of SARS both from Beijing and the outside world. But the system is patchy and the ability to react quickly with appropriately trained medical and public health professionals is still sadly lacking.